The vast majority of oral contraceptives consist of a combination of a progestin and estrogen that are administered concurrently for 21 days followed either by a 7 day pill free interval or by the administration of a placebo for 7 days in each 28 day cycle. The most important aspects of a successful oral contraceptive product are effective contraception, good cycle control (absence of spotting and breakthrough bleeding and occurrence of withdrawal bleeding), and minimal side effects. Combination oral contraceptives have traditionally acted by suppression of gonadotropins. In addition, it appears that the progestin component is primarily responsible for contraceptive efficacy through inhibition of ovulation, and other peripheral effects which include changes in the cervical mucus (which increase the difficulty of sperm entry into the uterus) and the endometrium (which reduce the likelihood of implantation). The estrogenic component intensifies the anovulatory effect of the progestin, and is also important for maintaining cycle control.
Since the introduction of oral contraceptives (OCs) over a quarter-century ago, research has been directed toward developing preparations that minimize the potential for side effects while maintaining efficacy and normal menstrual patterns. The first-generation OCs contained more progestin and estrogen than was necessary to prevent conception. Adverse hemostatic and metabolic changes, clinical problems, and side effects were associated with these high-dose preparations. In 1978, the World Health Organization (WHO) recommended that the focus of OC research should be the development of products containing the lowest possible dose levels of estrogen and progestin.
The first reductions in steroid content in a combination pill were focused on estrogen because it, rather than progestin, was thought to be related to the most serious side effects. Reduction in progestin content followed, as evidence mounted that lowering progestin intake might lower the risk of cardiovascular complications such as stroke and ischemic heart disease. [Kay CR, Am J Obstet Gynecol 142:762 (1982)]. However, this evidence was not as clear as that implicating estrogen in thromboembolic disorders. [Inman WHW, Br Med J 2:203 (1970); Stolley PD, Am J Epidemiol 102:197 (1975)]. The need for a balance between estrogens and progestins to minimize adverse effects on carbohydrate metabolism and on lipid and lipoprotein levels was also recognized. [Bradley DD, N Engl J Med 299:17 (1978); Wynn V, Lancet 1:1045 (1979)]. Researchers then found that the synergistic action between progestin and estrogen in a balanced ratio successfully inhibited ovulation at low levels of both components.
Research into low-dose progestins was advanced significantly by the development of norgestrel (Ng) and levonorgestrel (LNg). Levonorgestrel is the biologically active moiety of racemic norgestrel. It is strongly progestational, has no inherent estrogenic activity, is antiestrogenic, and possesses good biologic activity. The contraceptive effects of levonorgestrel are manifested throughout the hypothalamic-pituitary-gonadal-target organ axis.
Ethinyl estradiol (EE) is the estrogen most frequently used in combination OCs. In attempts to fulfill the WHO objective, the dosage of EE in marketed OC formulations has been steadily reduced from that found in earlier OCs. Thromboembolic mortality decreased when the amount of synthetic estrogen in OC formulations was reduced from 100 xcexcg to 50 xcexcg. Subsequently, a significant reduction in fatal myocardial infarctions was reported for women using OCs with 30 xcexcg of EE rather than 50 xcexcg of EE. [Meade TW,Br Med J 280:1157 (1980)].
In keeping with the goal of reducing the total steroidal dosage, while maintaining contraceptive efficacy, good cycle control, and minimizing side effects, numerous regimens have been developed in which the progestin/estrogen combination is administered either as a fixed dosage combination (monophasic) or as biphasic or triphasic regimens in which the dosage of the combination is varied either once or twice throughout the menstrual cycle. In these regimens, the progestin/estrogen combination is typically administered for 21 days followed by either a 7-day pill free period or the administration of a non-contraceptive placebo (or iron supplement) for 7 days. In these regimens, 3-ketodesogestrel (3-KDSG), desogestrel (DSG), levonorgestrel (LNg), gestodene (GTD), norgestrel (NG), and norethindrone (NE) are typically used as the progestin while ethinyl estradiol (EE); 17xcex2-estradiol, and mestranol are typically the estrogenic components. Other progestins less frequently used include drospirenone (DRSP) and dienogest (DGST).
An oral contraceptive product containing a combination of 3 mg DGST and 30 xcexcg EE for 21-day administration per cycle is marketed in Germany.
Several examples of attempts at reducing the total steroidal dosage are provided below.
Spona (PCT Publication WO 95/17194) discloses contraceptive regimens which consist of the administration of a combination of a progestin (50-75 xcexcg GTD, 75-125 xcexcg LNg, 60-150 xcexcg DSG, 60-150 xcexcg 3-KDSG, 100-300 xcexcg DRSP, 100-200 xcexcg cyproterone acetate, 200-300 xcexcg norgestimate, or  greater than 350-750 xcexcg norethisterone) and anestrogen (15-20 xcexcg EE or 2-6 mg 17xcex2-estradiol) for 23-24 days per cycle.
Oettel (EP 628,312 A1) discloses combination contraceptive combinations containing the combination of three components: a biogenic estrogen (estradiol, estrone, or estriol), a synthetic estrogen (EE or mestranol), and a progestin (LNg, desogestrel, progesterone, norethisterone acetate, DGST, chlormadinone acetate, gestodene, or cyproterone actate). In one embodiment, the combination is administered for 21 days followed by the administration of placebo (or pill free) or an estrogen on days 22-28 of the cycle.
Bergink (U.S. Pat. No. 5,262,408) discloses a 24 day triphasic combination regimen in which the first 7-9 day phase consists of the administration of a progestin at a daily dosage equivalent to 100 xcexcg DSG and an estrogen at a daily dosage equivalent to 25 xcexcg EE, the second 7-9 day phase consists of the administration of a progestin at a daily dosage equivalent to 125 xcexcg DSG and an estrogen at a daily dosage equivalent to 20 xcexcg EE and the third 7-9 day phase consists of the administration of a progestin at a daily dosage equivalent to 50 xcexcg DSG and an estrogen at a daily dosage equivalent to 20 xcexcg EE. It is preferred that the three phases be 8 days each. Following the 24 day contraceptive steroid administration, a placebo may be administered for 4 days, the 4 day interval may be pill free, or a progestin at a dosage equivalent to 25-35 xcexcg DSG may be administered.
Lachnit-Fixson (U.S. Pat. No. 3,957,982) discloses triphasic 21-day progestin/estrogen regimens in which a combination of 40-90 xcexcg LNg and 20-50 xcexcg EE is administered for 4-6 days in the first phase, 50-125 xcexcg LNg and 30-50 xcexcg EE is administered for 4-6 days in the second phase, and 100-250 xcexcg LNg and 25-50 xcexcg EE is administered for 9-11 days in the third phase. It is preferred that the first, second, and third phases are 6, 5, and 10 days, respectively.
Bennick (U.S. Pat. No. 5,418,228) discloses triphasic regimens which consist of the administration of a combination progestin/estrogen in a 6-8 day phase, a second 6-8 day phase, and a third 6-8 day phase, with it being preferred that the three contraceptive steroid phases be 7 days each. Bennick discloses that the first contraceptive steroid phase consists of a progestin at a daily dosage equivalent to 75-150 xcexcg DSG and an estrogen at a daily dosage equivalent to 20-25 xcexcg EE; the second contraceptive steroid phase consists of a progestin at a daily dosage equivalent to 75-125 xcexcg DSG and an estrogen at a daily dosage equivalent to 20 xcexcg EE; and the third contraceptive steroid phase consists of a progestin at a daily dosage equivalent to 75-100 xcexcg DSG and an estrogen at a daily dosage equivalent to 20 xcexcg EE. Placebo is administered for 7 days following the 21-day contraceptive steroid period. Bennick discloses that the progestin may be 3-KDSG, DSG, LNg, or GTD.
Boissonneault (U.S. Pat. No. 4,962,098) discloses triphasic progestin/estrogen combinations in which the amount of the estrogenic component is increased stepwise over the three phases. Contraceptive steroid combinations are taken for 47 days during the first phase (5 days being preferred); for 5-8 days during the second phase (7 days preferred); and for 7-12 days during the third phase (9 days being preferred). Following the administration of 21-days of the contraceptive steroid combination, placebo is taken for 7 days. For all three phases, 0.5-1.5 mg of norethindrone acetate is used in the progestin, with 1 mg being preferred. 10-30 xcexcg EE is used in the first phase, 20-40 xcexcg in the second, and 30-50 xcexcg in the third phase.
Pasquale (U.S. Pat. No. 4,921,843) discloses combination progestin/estrogen contraceptive regimens which contain 0.5 to 1 mg of progestin and an estrogen having a dose equivalent to 10-40 xcexcg of EE. NE, LNg, D-17xcex2-acetoxy-13xcex2-ethyl-17xcex1-ethinyl-gon-4-en-3-one oxime, and 19-nor-17-hydroxy progesterone ester are disclosed as progestins, with NE being preferred. Specifically disclosed regimens include a uniphasic regimen (2 days of placebo, 5 days of 20 xcexcg EE, and 21 days of a combination of 500 xcexcg NE and 35 xcexcg EE); a uniphasic regimen (2 days of placebo, 5 days of 40 xcexcg EE, and 21 days of a combination of 500 xcexcg NE and 35 xcexcg EE); and a triphasic regimen (2 days of placebo; 5 days of 20-40 xcexcg EE; 7 days of a combination of 500 xcexcg NE and 35 xcexcg EE; 7 days of a combination of 750 xcexcg NE and 35 xcexcg EE; and 7 days of a combination of 1 mg NE and 35 xcexcg EE).
Pasquale (U.S. Pat. No. 4,628,051) discloses triphasic progestin/estrogen combination regimens in which contraceptive steroid is administered for 21 days. Contraceptive steroid combinations are taken for 5-8 days during the first phase (7 days being preferred); for 7-11 days during the second phase (7 days preferred); and for 3-7 days during the third phase (7 days being preferred). In all three phases, an estrogen at a daily dosage equivalent to 20-50 xcexcg EE is administered in combination with a progestin having a daily dosage equivalent to 65-750 xcexcg NE in the first phase, 0.25-1.0 mg NE in the second phase, and 0.35-2.0 mg NE in the third phase. A specific triphasic regimen discloses the administration of 35 xcexcg EE in each of the free 7-day phases in combination with 0.5 mg, 0.75 mg, and 1.0 mg in the first, second, and third phases, respectively. A second specific triphasic regimen discloses the administration of 35 xcexcg EE in each of the three 7-day phases in combination with 50 xcexcg, 75 xcexcg, and 100 xcexcg in the first, second, and third phases, respectively. A third specific triphasic regimen discloses the administration of 35 xcexcg EE in each of the Free 7-day phases in combination with 25 xcexcg, 35 xcexcg, and 50 xcexcg in the first, second, and third phases, respectively.
Lachnit-Fixson (U.S. Pat. No. 4,621,079) discloses triphasic 21-day progestin/estrogen combination regimens in which a combination of 40-70 xcexcg GTD and 20-35 xcexcg EE is administered for 4-6 days in the first phase; 50-100 xcexcg GTD and 30-50 xcexcg EE is administered for 4-6 days in the second phase; and 80-120 xcexcg GTD and 20-50 xcexcg EE is administered for 9-11 days in the third phase. Placebo is administered for 7 days following the 21-day contraceptive steroid regimen.
Pasquale (U.S. Pat. No. 4,530,839) discloses triphasic 21-day progestin/estrogen combination regimens in which a dose of 20-50 xcexcg EE is administered in all free phases in combination with a contraceptively effective daily dose of progestin in the first phase, 1.5-2 times that dose of progestin in the second phase, and 2-2.5 times the first phase dose of progestin in the third phase. Each of the three phases is 7 days long. A specific regimen discloses 20-50 pg EE in combination with 500 xcexcg LNg, 750 xcexcg LNg, and 1 mg LNg during each of the three 7-day phases, respectively.
Edgren (U.S. Pat. No. 4,390,531) discloses triphasic 21-day progestin/estrogen combination regimens in which a dose of 20-40 xcexcg EE (or another estrogen in an equivalent dosage) is administered in all three phases in combination with 0.3-0.8 mg NE (or another progestin in an equivalent dosage) for 5-8 days in the first phase, twice the dose of NE for 7-11 days in the second phase, and the dose of NE being the same as in the first phase for 3-7 days in the third phase. It is preferred that each of the three phases is 7 days. Placebo is administered for 6-8 days following administration of the contraceptive steroid combination. A specific regimen discloses a first phase of 7 days of 0.5 mg NE in combination with 35 xcexcg EE, a second 7 day phase of 1.0 mg NE in combination with 35 xcexcg EE, and a third 7 day phase of 0.5 mg NE in combination with 35 xcexcg EE.
Upton (EP Patent Specification 253,607 B1) teaches the use of low dose progestin/estrogen combinations for combined hormone replacement therapy and contraception in climacteric women. Climacteric women are defined in Upton as premenopausal women around 40 years of age whose hormone levels are waning. The climacteric woman still ovulates (albeit may have irregular ovulation), but she still experiences many of the symptoms of the hypoestrogenic menopausal woman, such as insomnia, hot flushes, and irritability. Upton teaches the administration of a 23-26 day monophasic regimen of progestin/estrogen followed by a pill free or placebo interval of 2-5 days; with 24 days of progestin/estrogen administration followed by a 4-day pill free or placebo administration being preferred. Upton teaches the use of a progestin selected from 25-100 xcexcg LNg, 10-70 xcexcg GTD, 25-100 xcexcg DSG, 25-100 xcexcg 3-KDSG, and 85-350 xcexcg NE used in combination with an estrogen selected from 500-2000 xcexcg 170-estradiol, 8-30 xcexcg EE, and 15-60 xcexcg mestranol. Based on relative potencies, Upton teaches that a dose of 75 xcexcg LNg is equivalent to 35 xcexcg of GTD, 75 xcexcg of 3-KDSG or DSG, and 250 xcexcg NE and that a dose of 1000 xcexcg of 17xcex2-estradiol is equivalent to a dose of 15 xcexcg EE and 30 xcexcg mestranol. Upton also teaches that NG may be substituted for LNg, but at twice the dose.
Sartoretto (Clinica e Terapeutica 3: 399 (1974)) discloses a monophasic contraceptive regimen consisting of the administration of a combination 100 xcexcg LNg and 20 xcexcg EE for 21 days.
Oettel (EP 696,454 A2) discloses a three phase contraceptive regimen in which the first phase consists of the administration for 3-4 days of a composition containing at least one biogenic estrogen; the second phase consists of the administration for 20-22 days of at least one biogenic estrogen and at least one progestin (progesterone, DGST, desogestrel, 3-KDSG, GTD, LNg, norgestimate, notethisterone, norethisterone acetate, dehydrogestrone, chloromadinone acetate, cyproterone acetate, medroxyprogesterone acetate, or megestrol acetate); and the third phase consists of the administration for 3-4 days of a composition containing at least biogenic one estrogen.
Lachnit (PCT Publication WO 95/26730) discloses bridged regimens consisting of the administration of a combination of a progestin/estrogen combination (50-125 xcexcg LNg and 10-40 xcexcg EE) for the first 23-24 days of the menstrual cycle followed by the administration of an estrogen (2-40 xcexcg EE) for 4-10 days for a total administration of at least 28 days per cycle. The use of 100-300 xcexcg drospirenone and 10-40 xcexcg EE as the 23-24 day progestin/estrogen combination is disclosed. Lachnit also discloses a triphasic plus bridging regimen (4-9 days, 4-9 days, 9-13 days, and 28 days for the three phases and estrogen phase, respectively) in which a combination of 50 xcexcg LNg and 20 xcexcg EE are administered in the first phase, a combination of 75 xcexcg LNg and 25 xcexcg EE are administered in the second phase, a combination of 100 xcexcg LNg and 20 xcexcg EE are administered in the third phase, and 10 xcexcg EE is administered in the estrogen phase. Other progestins disclosed include GTD, DSG, 3-KDSG, DRSP, cyproterone acetate, norgestimate, and norethisterone.
Moore (DE 4313926 A1) discloses bridged triphasic regimens consisting of the administration of a combination of 10-50 xcexcg LNg and 5-20 xcexcg EE from days 1-7 of the menstrual cycle; of 50-75 xcexcg LNg and 5-20 xcexcg EE from days 8-14 of the menstrual cycle; of 75-125 xcexcg LNg and 5-20 xcexcg EE from days 15-21 of the menstrual cycle; and 5-20 xcexcg EE from days 22-28 of the menstrual cycle.
Erlich (German Patent DE 4,104,385 C1 and U.S. Pat. No. 5,280,023) discloses sequential contraceptive regimens consisting of the administration of an estrogen which effects a disturbance of follicle stimulation, followed by the administration of a combination of a progestin/estrogen in a dose at least adequate to inhibit ovulation. The regimen is administered for a total of 28 days per cycle. It is preferred that the estrogen is administered for 5-14 days per cycle and the progestin/estrogen combination is administered for 23-14 days per cycle, so that the total administration is for 28 days per cycle. Specific regimens include (a) 4 mg estradiol for 7 days followed by 21 days of the combination of 1 mg norethisterone acetate and 4 mg estradiol; (b) 2 mg estradiol valerate for 7 days followed by 21 days of the combination of 2 mg chlormadinone acetate and 4 mg estradiol valerate; and (c) 20 xcexcg EE followed by 18 days of the combination of 150 xcexcg LNg and 20 xcexcg EE. Regimen (c) in Erlich provides a total steroidal load of 2.7 mg of LNg and 560 xcexcg EE per 28 day cycle.
Lachnit-Fixson (U.S. Pat. No. 3,969,502) discloses biphasic progestin/estrogen combination regimens in which a combination of 50-125 xcexcg LNg and 25-35 xcexcg EE are administered for 10-12 days in the first phase and 100-350 xcexcg LNg and 30-50 xcexcg EE are administered for 10-12 days in the second phase. Placebo is administered for 5-7 days following the administration of the contraceptive steroid regimen.
This invention provides a tuiphasic combination progestin/estrogen oral contraceptive regimen for females of child-bearing age that provides effective contraception, good cycle control, and minimal side effects while greatly reducing the total contraceptive steroid administered (particularly the estrogenic component) per 28-day cycle. To achieve the substantial reduction in the total contraceptive steroid administered per cycle, the low dose progestin/estrogen combination is administered for 23-25-days per cycle according to a triphasic regimen that is described below. Administration of the contraceptive progestin/estrogen combination is begun on the first day of menses (day 1), and continued for 23-25 consecutive days. Following the 23-25-day administration peiiod, a non-contraceptive placebo (devoid of progestins and estrogens) can be provided for 3-5 days, so that the total administration period per cycle is 28 days per cycle to aid in compliance with the desired contraceptive regimen. Alternatively, the 3-5-day interval can be pill free.
More particularly, this invention provides a method of contraception which comprises administering to a female of child bearing age a first phase of a combination of a progestin at a daily dosage of 40-500 xcexcg trimegestone, 250 xcexcg-4 mg dienogest, or 250 xcexcg-4 mg drospirenone, and an estrogen at a daily dosage equivalent in estrogenic activity to 10-20 xcexcg ethinyl estradiol for 3-8 days beginning on day 1 of the menstrual cycle. The same daily dosage of the progestin and estrogen is administered for each of the 3-8 days. A second phase of a combination of a progestin at a daily dosage of 40-500 xcexcg trimegestone, 250 xcexcg-4 mg dienogest, or 250 xcexcg-4 mg drospirenone, and an estrogen at a daily dosage equivalent in estrogenic activity to 10-20 xcexcg ethinyl estradiol is administered for 4-15 days beginning on the day immediately following the last day of administration of the first phase. The same daily dosage of the progestin and estrogen is administered for each of the 4-15 days. A third phase of a combination of a progestin at a daily dosage of 40-500 xcexcg trimegestone, 250 xcexcg-4 mg dienogest, or 250 xcexcg-4 mg drospirenone, and an estrogen at a daily dosage equivalent in estrogenic activity to 10-20 xcexcg ethinyl estradiol at a daily dosage equivalent in estrogenic activity to 10-20 xcexcg ethinyl estradiol is administered for 4-15 days beginning on the day immediately following the last day of administration of the second phase. The same daily dosage of the progestin and estrogen is administered for each of the 4-15 days. The total administration for all three phases is 23-25 days. The daily dosage of the progestin/estrogen combination administered in any phase is distinct from the dosage of the progestin/estrogen combination administered in either of the other two phases.
Following the 23-25-day period, a non-contraceptive placebo, which may contain an iron supplement, such as 75 mg of ferrous fumarate, may be administered for 3-5 days (through day 28 of the menstrual cycle) or the 3-5 days following administration of the contraceptive combination may be pill free.